Acute Graft-Versus-Host Disease (GVHD)

Abstract

With a successful marrow transplant, the recipient’s lymphohemopoietic cells are replaced by donor-derived cells. Thus, in contrast to solid organ transplantation where the recipient’s immune system remains in place and attempts at immunosuppression are aimed at preventing the reaction of recipient cells against the transplanted organ, a double-barrier exists in marrow transplantation: transplanted marrow may fail to reconstitute successfully hemopoiesis in the recipient (graft failure due to immunological mechanisms or other factors) or donor lymphocytes may attack recipient tissue. While graft failure has generally been a problem only with HLA incompatible transplants, after marrow T-cell depletion and in some patients sensitized by prior transfusions, GVHD has been a major problem with all allogeneic transplants. We have to assume that in all instances of marrow transplantation an interaction between donor and host cells (graft-vs-host reaction) takes place. However, it was noted in early experiments that syngeneic, i.e., genetically identical marrow, could be transferred to a pretreated recipient without any clinically recognizable adverse reaction. In contrast, when marrow from an allogeneic donor was used a clinical syndrome developed which was originally termed secondary disease. This syndrome, subsequently called GVHD, is manifested mostly in skin, liver, and intestinal tract, although other targets such as the conjunctivae can be involved as well (see Table 15).